title: Allergy to rocuronium: from clinical suspicion to correct diagnosis.
abstract: BACKGROUND
  Allergy to rocuronium can be life-threatening. Correct diagnosis is a prerequisite because of serious consequences of diagnostic error.
  
  
  OBJECTIVE
  To assess skin testing, quantification of specific IgE (sIgE) and flow-assisted activation of basophils [basophil activation test (BAT)] in the diagnosis of rocuronium allergy.
  
  
  METHODS
  This study comprises 104 curarized patients with a history of profound hypotension and severe bronchospasm immediately after induction of anaesthesia. All patients had skin tests, quantification of sIgE and BAT to rocuronium, together with investigations for all relevant compounds administered during anaesthesia that could have evoked the reaction. Diagnosis of rocuronium allergy was considered definite when the patient demonstrated a positive outcome for at least two of the three aforementioned tests.
  
  
  RESULTS
  The positive predictive value for skin testing, BAT and sIgE was 98% (CI 95%: 92-99%), 97% (CI 95%: 88-100%) and 83% (CI 95%: 74-89%), respectively. The negative predictive value for skin testing, BAT and sIgE was 96% (CI 95%: 86-99%), 75% (CI 95%: 67-75%) and 72% (CI 95%: 58-83%), respectively. Cross-reactivity with vecuronium was documented in 69% of the patients.
  
  
  CONCLUSIONS
  Skin testing merits the status of primary diagnostic investigation to document rocuronium allergy and cannot be substituted by quantification of sIgE or BAT. SIgE can offer a diagnostic advantage in cases where skin tests yield negative results. However, additional tests (e.g. BAT) are of capital importance in patients with negative skin tests and positive sIgE results to help in interpreting the clinical significance of a positive sIgE result. Optimal assessment of cross-reactivity between rocuronium and vecuronium implies both skin testing and BAT.
authors.affiliation: Department of Immunology, University of Antwerp, Antwerp, Belgium.
authors.forename: J
authors.initials: J
authors.lastname: Leysen
authors.forename: C H
authors.initials: CH
authors.lastname: Bridts
authors.forename: L S
authors.initials: LS
authors.lastname: De Clerck
authors.forename: M
authors.initials: M
authors.lastname: Vercauteren
authors.forename: J
authors.initials: J
authors.lastname: Lambert
authors.forename: J J
authors.initials: JJ
authors.lastname: Weyler
authors.forename: W J
authors.initials: WJ
authors.lastname: Stevens
authors.forename: D G
authors.initials: DG
authors.lastname: Ebo
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000732:Androstanols / Q000009:adverse effects* / Q000276:immunology; D001491:Basophils / Q000276:immunology; D004342:Drug Hypersensitivity / Q000175:diagnosis*; D005260:Female; D006801:Humans; D006967:Hypersensitivity / Q000175:diagnosis*; D007073:Immunoglobulin E / Q000032:analysis; D008297:Male; D008875:Middle Aged; D003473:Neuromuscular Nondepolarizing Agents; D011237:Predictive Value of Tests; D011446:Prospective Studies; D000077123:Rocuronium; D012882:Skin Tests; D014673:Vecuronium Bromide / Q000009:adverse effects; D055815:Young Adult
chemical_list: D000732:Androstanols; D003473:Neuromuscular Nondepolarizing Agents; D007073:Immunoglobulin E; D014673:Vecuronium Bromide; D000077123:Rocuronium